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We recommend that each household breadwinner
carry ten times their annual income in total life insurance.
Caregiving adults who are responsible for others should
consider $300,000. If you need personalized advice, call
our life insurance counselors at 1-800-324-6370 or click here to view our online life insurance needs calculator.

All life insurers ask about and rate for tobacco use, including any history of cigarette, pipe, chew, patch or gum, so please be 100% honest when you answer this question so that you can receive accurate rate quotes. Sources of information include your application statements, your paramed exam results, your outside medical records and your Medical Information Bureau (MIB) file. And remember, a false statement on an application for insurance could void your coverage. If you need personalized advice, call our life insurance counselors at 1-800-324-6370.

Height:

Weight (with clothes on):

Why does the life insurance company need to know your actual weight?

Weight (with clothes on) is a key rating factor with all life insurance companies. Please give an honest answer here so that you can receive accurate rate quotes. And keep in mind that the paramed examiner who visits you will be carrying a portable scale, so be honest here. If you need personalized advice, call our life insurance counselors at 1-800-324-6370.

Have you bought a personal (not work-related or group) term
life insurancepolicy that required a paramedical exam within the last 60 months?

No
Yes

Choose One:
I am in good health
and have taken no prescription drugs
over past 5 years.New! Show me custom quotes based upon my
own health history and lifestyle.

Complete all fields below so that we can now refine your
quote
to your own health history. This ensures lowest possible pricing.

Have you received disability benefits or any form of government assistance
within the last 6 months?

No
Yes

Please provide details including cause and date(s):

Do you intend to fly as a Private Pilot?

Why am I being asked about private pilot
intentions?

All life insurers ask about your intentions to pilot or act as a crew member on any private aircraft,
which also includes balloons and gliders. Private pilots who wish to have life insurance coverage in force while
they are piloting a private aircraft are normally asked to complete an Aviation Questionnaire as a routine part
of underwriting. Our life insurance counselors are skilled and experienced at helping private pilots obtain life
insurance at the lowest possible rates, so please call us at 1-800-324-6370 if you have any questions or
need assistance.

No Yes

Within the last 5 years, have you been convicted of either reckless
driving or driving while under the influence, received 3 or more moving violations or had your license
suspended/revoked or had any other convictions or law enforcement infractions of any kind?

No Yes

Please explain item and give date(s):

Do you currently have a personal bankruptcy filing that has not been
discharged or does not yet have a repayment plan established?

No
Yes

Please explain item and give date(s):

Do you intend to participate in scuba diving?

No
Yes

Do you expect to make more than 10 dives in the next 12 months?

No Yes

What is the maximum depth to which you will dive?

Are you a certified dive instructor or professional diver?

No Yes

Do you participate in any technical or high risk dives, including
but not limited to cave, ice, or salvage diving?

No Yes

Do you intend to: travel to any country shown on the U.S. State Department's
Travel Warnings list, mountain climb, rock climb, skydive, race a motorized vehicle, or engage in any hazardous activity;
or do you have a history of any criminal conviction that we should know about in order to give you an
accurate quote?

No Yes

Please provide specific details including dates:

Do you recall your last blood pressure reading?

Why am I being asked about my blood pressure?

Hypertension, also called "elevated blood pressure" or "high blood pressure", is looked at closely by
all life insurance companies. If you don't remember your last readings, it's OK to choose "I don't know" as your
answer. In that case, we'll assume that you do not have a history of hypertension and we will show you the
lowest possible rates. If you choose a plan that requires a paramedical exam, which is really a face-to-face
interview or "mini-medical" then our technician will check your blood pressure at that time. If you need
personalized advice or help, call our insurance counselors at 1-800-324-6370.

Are you taking blood pressure medication?

No
Yes

Date of Onset

Date of
last Dr. visit

Current Medication

Daily Dosage

Do you recall what your last cholesterol level was?

Are you taking cholesterol medication?

No Yes

Date of Onset

Date of
last Dr. visit

Current Medication

Daily Dosage

Any family (parents or siblings) diagnosed with
cardiovascular disease (heart disease or stroke)
or cancer before age 60?

No
Yes

Which family member(s) were diagnosed before age 60? (Click all
that apply).

Cancer
diagnosis
before age 60

Cancer
death
before age 60

Cardiovascular
diagnosis
before age 60

Cardiovascular
death
before age 60

Mother

Father

Sibling

Have you ever been rated up or declined by any life insurance
company?

No
Yes

Name of company

Date of Application

Declined or Rated

Reason for
Decline or Rate-Up

How many doctors or health care professionals have
you seen in the last 5 years?

Has any doctor recommended any medical test or procedure that you
have not yet completed?

No Yes

In the past 10 years, have you had or been
treated for any of the following conditions?

Alcohol Abuse

Anxiety, ADD, ADHD or Depression

Asthma

Cancer (Skin Only)

Drug Abuse or Addiction

Gastric/Peptic Ulcers

Recurrent Kidney Stones

Alcohol Abuse Questionnaire

Date of first diagnosis:

How long did the abuse continue?

Were there any relapses from sobriety/abstinence?

No
Yes

Date:

Is there any current alcohol usage?

No
Yes

Frequency and amount:

Date of last alcohol consumption:

Were there any legal problems (such as DUI or other)?

No
Yes

Date:

Ever had any of the following occurrences or symptoms?

Elevated Liver Enzymes

Positive Alcohol Marker

If elevated liver enzymes, are current enzyme levels normal:
No
Yes

Blackouts

Withdrawal Seizures

Alcohol Related Medical Complications

Family/Friends Concern Over Drinking Habits

Alcohol Related Medical Complications date and details:

Use Of Other Substances Such as Marijuana Or Cocaine

Other substances abused details:

Have there been any hospitalizations for this condition?

No
Yes

Dates and details:

Do you currently participate in a group such as Alcoholics Anonymous?

No
Yes

Has therapy been done for this condition?

No
Yes

Details:

Are any medications being taken for this condition?

No
Yes

Details:

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Details:

Comments:

Anxiety/ADD/Depression/Mental Illness Questionnaire

Indicate diagnosis:

Anxiety/Depression

When was the condition diagnosed?

What caused the condition?

Are you taking/Have you taken medication for this condition?

No
Yes

List type of medication(s), dosage, and date of use:

Are you seeing/have you seen a therapist for this condition?

No
Yes

List date of last consultation:
NOTE: If applicant is currently taking medication for anxiety, ADD, depression or mental illness, most, if not all, life companies will want to see a doctor visit within last 12 months to prove that patient is compliant and receiving ongoing psychiatric care.

Are you employed?

No
Yes

Has time been lost at work for this condition?

No
Yes

Have you received/Are you receiving disability benefits for this condition?

No
Yes

Have you attempted suicide or been hospitalized for this condition?

No
Yes

Details:

ADD/ADHD

When was the condition diagnosed?

Are you taking/Have you taken medication for this condition?

No
Yes

List type of medication(s), dosage, and date of use:

Are you employed?

No
Yes

Have you received/Are you receiving disability benefits for this condition?

List date of last consultation:
NOTE: If applicant is currently taking medication for anxiety, ADD, depression or mental illness, most, if not all, life companies will want to see a doctor visit within last 12 months to prove that patient is compliant and receiving ongoing psychiatric care.

Are you employed?

No
Yes

Has time been lost at work for this condition?

No
Yes

Have you received/Are you receiving disability benefits for this condition?

No
Yes

Have you attempted suicide or been hospitalized for this condition?

No
Yes

Details:

Do you have a history of substance abuse (alcohol or drug)?

No
Yes

Details:

Have you been hospitalized, required ECT, been seen in the emergency room, or been on disability for psychiatric symptoms or treatment?

No
Yes

Details:

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Details:

Comments:

Asthma Questionnaire

Date when first diagnosed:

Age when first diagnosed:

Describe frequency and symptoms:

Is there a trigger for attacks (e.g stress, allergies, exercise, etc.)?

No
Yes

Details:

Are there any episodes within 5 years requiring ER visits or hospitalization?

No
Yes

Details:

Has there been time lost at work or school due to this condition?

No
Yes

Details:

Have you ever smoked?

No
Yes

Date of last tobacco usage:

Including inhalers, are any medications being taken for this condition?

No
Yes

Name of medication and frequency of use:

Have pulmonary function or other tests been done?

No
Yes

Type of tests and results:

Do you have any abnormalities on an ECG or x-ray?

No
Yes

Details:

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Details:

Comments:

Skin Cancer Questionnaire

Please list date when first diagnosed:

What type of skin cancer was diagnosed:

Basal cell carcinoma

Squamous cell carcinoma

Malignant melanoma

Stage if available

Excised

Date:

Cryosurgery

Date:

Chemotherapy

Date:

Radiation

Date:

Ulcerated

Clark's Level

Thickness in mm

Any positive Lymph Node

No
Yes

Details :

Please note where the skin cancer was located:

Has the cancer metastasized(spread) beyond the skin?

No
Yes

Details:

Has there been any evidence of recurrence?

No
Yes

Details:

Are you on any medications?

No
Yes

Details:

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Details:

Comments:

Drug Abuse Questionnaire

Date of first diagnosis:

What types of drug(s) were used?

How often were the drugs used?

In what amount were the drugs used?

How long did the abuse last?

When was the date of last use?

Is there any history of drug overdose?

No
Yes

Please list dates:

Were there any relapses from sobriety/abstinence?

No
Yes

Please list dates:

Were there any legal problems (such as DUI or other)?

No
Yes

Please give details including dates:

Have there been physical complications or additional psychiatric problems?

No
Yes

Please give details:

Please list current medications:

Is there any current use of alcohol?

No
Yes

Amount and frequency:

Was there participation in a drug rehabilitation program(s)?

No
Yes

Date and name of program:

How long did the program last?

In-Patient

Out-Patient

Has there been/Is there any participation in recovery groups(such as Narcotics Anonymous)?

No
Yes

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Please give details:

Are you currently working part-time?

No
Yes

Are you currently working full-time?

No
Yes

Are you currently married?

No
Yes

Comments:

Gastric/Peptic Ulcers Questionnaire

Please list date when first diagnosed:

Please note how the ulcer was treated:

Medications only

Details:

Surgery only

Date and type of surgery:

Was repeat surgery required?

Both

Medications details:

Date and type of surgery:

Was repeat surgery required?

Have there been any recurrences or more than one episode?

No
Yes

How many episodes?

Date, duration, and severity of attack:

Are you on any medications?

No
Yes

Please give details:

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Please give details:

Comments:

Recurrent Kidney Stones Questionnaire

Please list date when first diagnosed:

Date of most recent attack:

How many episodes have you had?

How many total stones have there been?

Have you ever been hospitalized for this condition?

No
Yes

Details:

Has any special testing been done, such as kidney function tests?

No
Yes

Type of tests:

Test results:

Please list the type of treatment received:

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Details:

Comments:

For what medical conditions have you EVER
been diagnosed, treated or prescribed any medication?

Alzheimer's

Artery (Coronary) Disease

Cancer (Other Than Skin)

Colitis or Ileitis

COPD

Crohn's Disease

Diabetes

Emphysema

Epilepsy

Fibromyalgia

Gout

Heart Disease or Abnormal EKG

Hepatitis or Liver Disease

HIV

Hypothyroidism

Kidney Disease

Leukemia

Lupus

Melanoma

Mental Illness

Mitral Valve Prolapse

Multiple Sclerosis

Parkinson's Disease

Prostate Cancer

Prostate Issues

Rheumatoid Arthritis

Sarcoidosis

Sleep Apnea

Stroke

Vascular Disease

Other

Have you been diagnosed with any other health
conditions not listed above?

No
Yes

Describe health conditions not listed above

Name all prescription drugs that you've taken in past 5 years and
for what medical
reason(s) was each drug prescribed:

Medications Taken

Medical Condition

Current Daily Dosage

Diabetes Questionnaire

What type of Diabetes do you have?

Type I (Juvenile)
Type II (Adult onset)

Date Diagnosed:

Age Diagnosed:

How often do you visit your physician?

Date you last visited your physician:

The diabetes is controlled by:

Diet alone

Oral medication

Medication and doses :

Insulin

Amount of units/day :

Are you on any other medications?

No
Yes

Details:

Do you monitor your own blood sugar?

No
Yes

If available, please give the most recent glycohemoglobin(HbA1c) or fructosamine level:

Please check if you have had any of the following:

Chest Pain or coronary artery disease

Overweight

Protein in the urine

Elevates lipids

Neuropathy

Black out spells

Retinopathy

Hypertension

Abnormal ECG

Have you smoked cigarettes in last 12 months?

No
Yes

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Details:

Comments:

Sleep Apnea Questionnaire

Please list date when first diagnosed:

Has a sleep study been recommended?

No
Yes

Was it done?

No
Yes

Date:

Why not?:

Was the sleep apnea diagnosed as:

Obstructive

Central

Unknown

How is the sleep apnea being treated?

Observation alone

Weight loss

C PAP/BiPAP mask

Surgery

Other

Details :

Are you on any medications?

No
Yes

Details:

What was your last AHI (apnea-hypopnea index) reading:
OR
I don't know

What was your last O2 (Oxygen) Saturation Level reading:
OR
I don't know

Please check if you have had any of he following:

Lung disease

Accidents such as motor vehicle accidents

Heart disease

Arrhythmia

Stroke

Depression

Hypertension

Sarcoidosis

Do you smoke?

No
Yes

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Details:

Comments:

Cancer(non-skin) Questionnaire

List tissue of origin and kind of cancer diagnosis you have (i.e. colon, breast, liver, etc.)

Date of first diagnosis:

Grade, stage, and/or tumor size:

Did the cancer metastasize?

No
Yes

Where to?

How was the cancer treated?

Observation only

Date completed:

Surgery

Date completed:

Chemotherapy

Date completed:

Radiation therapy

Date completed:

Hormone therapy

Date completed:

Other :

Date completed:

Date cancer was declared "in remission":

Any evidence of recurrence since treatment completed?

No
Yes

Details:

List all medications being taken now for this condition:

List all medications being taken now for any condition:

Date and results of last doctor visit for this condition:

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Details:

Comments:

Vascular / Heart Disease or Abnormal EKG Questionnaire

List history of vascular or heart disease (i.e. what is
diagnosis?)

Date of first diagnosis:

What was your age when diagnosed with this condition?

Ever had any of the following occurrences or symptoms?

Chest Pain

Trouble Breathing

Heart Failure

Heart Palpitations

Atrial Fibrillation/Flutter

Abnormal EKG

Enlarged Heart

Have you ever smoked?

No
Yes

Date of last tobacco usage:

Have any of the following tests been done or recommended?

Echocardiogram

Were there any ST or T wave changes
No
Yes

Exercise Treadmill or Thallium

Date:

Stress Test

Date:

Results:

Other

Details:

Ever had any of the following procedures done or recommended?

Cardiac Catheterization

How many?

Date:

Coronary Angioplasty

How many?

Date:

Coronary Artery Bypass Graft

How many?

Date:

Coronary Defibrillator

Date:

Coronary Stent

How many?

Date:

Coronary Pacemaker

Date:

Valve Surgery

Which valve?

Date:

Are you taking medications for the condition (including aspirin)?

No
Yes

Details:

Are there any restrictions on daily activities?

No
Yes

Details:

What is date and result of last checkup with any heart specialist for this condition?

Note: Underwriters typically require current (within last 24 months) cardiac follow-up on your part and compliance with your doctor's recommendations given that cardiac-related death is #1 cause of death in the U.S. All cardiac and cardiac-related medical records are looked at very closely by the life underwriter and compliance with your doctor's instructions and regular checkups are critical to getting a good life insurance offer.

Are you in compliance with your doctor's recommendations?

No
Yes

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Details:

Comments:

COPD Questionnaire

Date of first diagnosis:

Ever had any of the following occurrences or symptoms?

Chronic Bronchitis

Emphysema

Restrictive Lung Disease

Asthma

List all medications being taken(include inhalers).

Ever had any abnormalities associated with ECG or x-ray?

No
Yes

Details:

Have pulmonary function tests (a breathing test) ever been done?

No
Yes

Details:

Has your client ever been hospitalized for this condition?

No
Yes

Details:

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Details:

Comments:

Melanoma Questionnaire

Date of first diagnosis:

Please note where the melanoma was located:

Which type of melanoma were you diagnosed with?

Superficial Spreading Melanoma

Nodular Melanoma

Lentigo Maligna Melanoma

Acral Lentiginous Melanoma

Other:

For malignant melanoma only. Please provide all items:

Stage if available

Ulcerated

No
Yes

Clark's Level

Thickness in mm

Any positive Lymph Node

No
Yes

Details :

Has the cancer metastasized (spread) beyond the skin?

No
Yes

Details:

Has there been any evidence of recurrence?

No
Yes

Details:

List all medications being taken(include inhalers)?

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Details:

Comments:

Prostate Cancer Questionnaire

Date of biopsy:

Month
Year

How was the cancer treated?

Observation only

TURP (Transurethral Prostatectomy)

Radical Prostatectomy

Radiation Therapy (Seed implant or external beam
radiation)

Date radical prostatectomy completed:

Month
Year

Hormone therapy

Other :

Date treatment completed:

List all medications being taken now for any condition?

What stage was the cancer?

What was the Gleason score?

When was the most recent PSA test?

What was the result of the most recent PSA test?

Less than 1
1 or higher

Please provide the most recent PSA level:

What was the PSA prior to treatment?

Has there been any evidence of recurrence?

No
Yes

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Details:

Comments:

Mitral Valve Prolapse Questionnaire

Date of first diagnosis:

How long has this abnormality been present?

Ever had any of the following occurrences or symptoms?

Chest Pain

Palpitations

Trouble Breathing

Dizziness

Is the MVP associated with regurgitation?

No
Yes

Is there a history of any other heart disease in addition
to the mitral valve prolapse (problems with other valves,
coronary artery disease, etc.)?

No
Yes

Details:

Has an echocardiogram (ultrasound of the heart) been done?

No
Yes

Details:

Is there a murmur?

No
Yes

What is the grade?

List all medications being taken now for any condition?

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Details:

Comments:

Crohn's Disease Questionnaire

Date of first diagnosis:

Ever had any of the following occurrences or symptoms?

Hospitalizations for this disorder (list dates)

List Dates:

Surgery for this disorder (list dates)

List Dates:

Colonoscopy (list dates of most recent)

List Dates:

List all medications being taken (prescription and/or
non-prescription)?

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Details:

Comments:

Hepatitis/Liver Disease Questionnaire

Date of first diagnosis:

What is the diagnosis?

Hepatitis A

Hepatitis B, resolved

Hepatitis B, carrier or chronic infection

Hepatitis C (non-A/non-B)

Jaundice

Fatty Liver

Cirrhosis

Other:

Have any of the following tests been done?

Liver Enzyme Tests

Date:

AST/SGOT

ALT/SGPT

GGPT

Liver ultrasound

Normal
Abnormal

CT scan/MRI

Normal
Abnormal

Liver biopsy

Normal
Abnormal

Do you drink alcohol?

No
Yes

What amount and frequency?

What type(s) of treatment have been/are being done?

Observation

Medication

Details:

Surgery

Date:

Have you been treated with interferon or anti-viral
drugs?

No
Yes

Details:

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Details:

Comments:

Stroke Questionnaire

Please indicate date(s) of episodes(s):

Do you have any current neurological residuals?

No
Yes

Date:

Ever had any of the following occurrences or symptoms?

High Blood Pressure

High Cholesterol

Coronary Artery Disease

Atrial Fibrillation

Diabetes

Peripheral Vascular Disease

Heart Murmur

Carotid Disease

List all medications being taken now for any condition?

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Details:

Comments:

Rheumatoid Arthritis Questionnaire

Date of first diagnosis:

Age at diagnosis:

Ever had any of the following occurrences or symptoms?

Weight Loss

Fever

Low Blood Counts

Heart Disease

Lung Disease

Liver Enzyme Abnormality

Kidney Disease

Other :

Which joints are involved?

Describe present symptoms:

List medications for this condition:

Have you ever taken steroids, gold, or immunosuppresive therapy?

No
Yes

Type and date range:

Please check functional ability:

Fully Active

Sedentary

Uses Walker, Cane, etc.

Uses Wheelchair

Are you receiving disability benefits?

No
Yes

List all medications being taken now for any condition?

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Details:

Comments:

Multiple Sclerosis Questionnaire

Please list date of first diagnosis:

Please indicate the number of episodes and date of last episode:&nbsp

Are you on any medications?

No
Yes

Please give details:

Please note current neurologic status and/or symptoms.

normal

minimal residual impairment

moderate residual impairment

severe residual impairment

Please specify:

Please provide all MRI brain scan reports:

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Please give details:

Comments:

Epilepsy Questionnaire

Please provide date of first episode/diagnosis:

Please provide date of most recent episode:

Please provide number of episodes per year:

Please note type of seizure:

Complex/Partial Seizure

Tonic-Clonic Seizure

Absense Seizure

Myoclonic Seizure

Are you on any medications?

No
Yes

Name of medication(s) amount and frequency:

Have you been hospitalized for treatment of epilepsy?

No
Yes

Please give details:

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Please give details:

Comments:

Emphysema Questionnaire

Please list date when first diagnosis:

Type of lung disease:

chronic bronchitis

emphysema

restrictive lung disease

asthma

Have you ever been hospitalized for this condition?

No
Yes

Please give details:

Are you on any medications (include inhalers)?

No
Yes

Please give details:

Have pulmonary function tests (a breathing test) ever been done?

No
Yes

Please give most recent test results
(date)

Do you have any abnormalities on an ECG or x-ray?

No
Yes

Please give details:

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Please give details:

Comments:

Colitis / Ileitis Questionnaire

Please list date of first diagnosis:

Please note the type of inflammatory bowel disease present:

Chronic Ulcerative Colitis

Chronic Proctitis (inflammation in rectum only)

Are you on any medications?

No
Yes

Please give details:

Please check if you have had:

hospitalizations for this disorder (list dates)

List Dates:&nbsp

surgery for this disorder (list dates)

List Dates:&nbsp

colonoscopy (list dates of most recent)

List Dates:&nbsp

Any other major illnesses; for example, cancer, diabetes or heart disease?

No
Yes

Please give details:

Comments:

Parkinson's Disease Questionnaire

Please list date of diagnosis:

Please note the functional stage of you currently:

Stage I unilateral involvement

Stage II bilateral involvement but normal stance

Stage III bilateral involvement with mild postural imbalance but able to lead an independent life